Hygiene

Bath Guidelines

Provide privacy. Maintain safety. Maintain warmth. Promote independence. Anticipate needs.

A nurse is caring for a patient who is on long-term bedrest and requires frequent linen changes due to excessive diaphoresis. Which of the following is the priority rationale for frequent linen changes? Moisture from excessive diaphoresis can cause skin breakdown. Moisture on the sheets can cause discomfort to the patient. It provides an opportunity to frequently evaluate the patient's skin on his back side. It provides an opportunity to turn the patient from side to side to facilitate clearing potential fluid from the lungs.

*Moisture from excessive diaphoresis can cause skin breakdown* ~The greatest risk to the patient is skin breakdown, which can result from increased contact with the moist sheets causing skin irritation and promoting bacteria growth. Therefore, the linens should be changed frequently. Moisture on the sheets can cause discomfort to the patient. ~Moisture can cause discomfort, but this is not the priority rationale for frequent linen changes. It provides an opportunity to frequently evaluate the patient's skin on his back side. ~Frequent evaluation of the patient's skin is important, but this is not the priority rationale for frequent linen changes. It provides an opportunity to turn the patient from side to side to facilitate clearing potential fluid from the lungs. ~Turning the patient to facilitate clearing potential fluid from the lungs is important, but this is not the priority rationale for frequent linen changes.

actors influence personal hygiene.

*social factors*- social groups influence hygiene preferences *personal preferences*- some individuals prefer to bath over showering *body image*- subjective view of body. bad body image results in less self hygiene. May prefer to wear makeup *socioeconomic status*- lack of money = lack of resources for hygiene *health beliefs/motivation*-patient teaching needed to promote health beliefs/motivations. ex; someone may be more motivated to brush teeth and floss by educating of dental caries culture- some cultures only wash once a week Developmental stage- stage of life determines care needed

HISTORY A 52-year-old male who weighs 220 pounds has transferred to your unit from the neurointensive care unit. He has an admission diagnosis of cerebrovascular accident and hypertension. He also has a history of type 2 diabetes mellitus, consumes two to three alcoholic drinks per week, and has smoked for the last 30 years. ASSESSMENT During assessment, you find that he is alert and oriented. His vitals are: blood pressure, 130/85; pulse, 72; and respirations, 20 breaths/min. His extremities are warm to touch, and he has weakness on his left side. Lastly, he says that he's having trouble seeing out of his left eye. You enter his room to provide him foot care. WHAT'S NEXT? 1.The first step of foot care is to assess the client's fingers, toes, feet and nails. You assess the radial pulse and dorsalis pedis of each hand and foot. It is important to check these pulses because it lets you know if the client A. is dehydrated. B. has adequate blood flow to extremities. C. has any problems in his heart. 2.You proceed with the process of foot care for this client. Which one of the following steps will you do for this diabetic client in order to get his feet cleaned? A. Wash his feet with lukewarm water and dry thoroughly between the toes. B. Allow the patient to soak his feet in basin of warm water for an hour. C. Clean his feet by rubbing a lotion all over his feet and toes. 3.After drying his toes and toe nails the client asks if his nails can be clipped. You should A. Use nail clippers to cut his nails through the corners and shape them around the edges. B. Use nail clippers to trim nails straight across and square file the edges. C. File his nails thoroughly including corners of toes. 4.After cleaning feet and toes, you should teach the client that in order to keep blood flowing to his feet adequately you advise him to A. Let his feet dangle down from side of bed for about 2 hours every day. B. Cross his legs and sit at edge of the bed for 1 hour twice a day. C. Keep his legs up when sitting and wiggle his toes.

1. A - INCORRECT No. This is not the correct choice. Checking the pulses is not to determine the hydration status of the client in this case. *B* - CORRECTYes. You have selected the correct response. Adequate pulses indicate adequate blood supply to the extremities and hence indicates healthy tissues which is so important to determine when assessing diabetic clients. C - INCORRECT No. This is not the correct choice. Checking pulses in this case is not to determine any abnormalities in the heart. 2. A - CORRECT Yes. This is to be done for diabetic clients or clients with peripheral arterial disease. This prevents the tissues from being macerated and prevents any infection occurring. B - INCORRECTNo. This is not the correct choice. Soaking feet in warm water for an hour is not done for diabetic clients. It macerates the tissues and will dry them out leading to tissue breakdown and infection. C - INCORRECT No. This is not the correct choice. This can be done only after washing and drying his feet thoroughly. For diabetic clients an emollient lotion can be applied over all surfaces of feet but not between the toes. 3. A - INCORRECT No. This is not the correct choice. This should not be done for diabetic clients since it can damage the tissues. *B* - CORRECTYes. You have selected the correct response. The American Diabetic Association (2010) recommends trimming nails straight across and square filing the edges smooth. Cutting nails including the edges as well as shaping corners can damage tissues which can lead to further infection and delayed healing in diabetic clients. C - INCORRECTNo. This is not the correct choice. Nails should be only trimmed straight across and square filed for diabetic clients. 4. A - INCORRECT No. This is not the correct choice. This action is not recommended. It does not cause adequate blood to flow to his feet. B - INCORRECTNo. This is not the correct choice. The American Diabetic Association recommends not to cross legs for long periods as this can reduce the blood flow to feet which can compromise oxygenation of tissues in the lower extremities. *C* - CORRECTYes. You have selected the correct response. The American Diabetic Association (2010) recommends that diabetic clients keep their feet up when sitting and wiggling their toes and move their ankles up and down for 5 minutes 2 or 3 times a day. This keeps blood flowing to the feet adequately well.

HISTORY Your patient, a 79-year-old-woman with a history of hypertension, type 2 diabetes mellitus, and hyperlipidemia, was just transferred from a surgical unit to the ICU due to a left-sided cerebrovascular accident 3 days after a left carotid endarterectomy. She is unresponsive and intubated, with marked motor deficits in her right arm and leg. ASSESSMENT You have received report from the nurse on the surgical floor and now approach the patient to perform your initial assessment and to give her personal hygiene. WHAT'S NEXT? After assessing the patient and completing the intake physical, you allow the patient to rest. When she awakens, you will give her a complete bed bath, being careful to minimize any risks associated with this procedure. 1.To reduce the risk of aspiration during the bath, you A. minimize mouth care, as the patient's gag reflex is probably diminished. B. have another staff member assist you with the procedure. C. place the patient in supine position. 2.You are now going to provide oral care to this patient. In preparation, you place the patient in A. a supine position. B. semi-Fowler's position. C. a side-lying position. 3.For an unconscious patient, you know that eye care A. should be provided frequently. B. includes using the same portion of a soft washcloth to clean both eyes. C. requires application of lubricating eye drops. 4.While washing the patient's lower back, you note an area near the sacrum that is erythematous and showing signs of further breakdown. You A. massage the area to improve circulation to the skin. B. gently wash the area with soapy water to help keep it clean. C. rub the area briskly with a towel after rinsing to dry it thoroughly. 5.You have completed your patient's bath, and now retrieve her dentures from her personal belongings. You care for the dentures appropriately by A. soaking the dentures in a denture cup filled with cleansing solution then rinsing them. B. placing them in a clean, dry storage container after thoroughly brushing them. C. brushing them with a toothbrush and denture cleaner and rinsing with tepid water.

1. A - INCORRECT No. This is not the correct choice. The combination of endotracheal intubation and the lack of oral intake can result in bacterial growth and dryness and discomfort for the patient. Thorough oral hygiene is essential for this patient. *B* - CORRECTYes. You have selected the correct response. Although not always possible, this is the ideal situation. Nursing assistive personnel can be delegated to help out. This staff member can intervene with suctioning while you are addressing the patient's hygiene needs. This helps you keep the patient safe during the bathing procedure. C - INCORRECT No. This is not the correct choice. The patient needs to be placed close to the side of the bed with the head of the bed raised to 30 degrees and the patient's head turned toward the mattress. The patient can also be placed on her side (Sims' position) with the side rail raised. Turning the patient's head toward the side allows secretions to drain from the mouth rather than collecting in the back of the pharynx. 2. A - INCORRECT No. This is not the correct choice. Lying flat increases an unresponsive patient's risk of aspiration. B - INCORRECTNo. This is not the correct choice. Sitting upright is an appropriate position for patients who can assist with oral care, not for those who cannot. This position could place an unconscious patient at risk for aspiration. *C* - CORRECT Yes. You have selected the correct response. This position provides adequate access to the oral cavity while allowing secretions to drain out of the patient's mouth. 3. *A* - CORRECT Yes. You have selected the correct response. Unconscious patients tend to develop crusty debris around the eyes that must be removed promptly. B - INCORRECTNo. This is not the correct choice. When cleaning the patient's eyes, use a different section of the washcloth for each eye. C - INCORRECTNo. This is not the correct choice. Lubricating eye drops should only be used according to a provider's prescription. 4. A. massage the area to improve circulation to the skin. A - INCORRECT No. This is not the correct choice. Applying pressure to an area of nonblanching erythema can cause further tissue damage. *B* - CORRECTYes. You have selected the correct response. This will minimize the risk of further loss of skin integrity, as gentle pressure will not macerate the epithelium. C - INCORRECTNo. This is not the correct choice. Although it is important to keep the area dry, gently patting is the preferred technique for drying skin after bathing, especially if the skin's integrity is questionable or 5.A - INCORRECT No. This is not the correct choice. Soaking dentures in a commercial cleaning solution can help remove staining, but it alone is not sufficient for adequate cleaning of dentures. B - INCORRECTNo. This is not the correct choice. Dentures should be kept moist when not in use to prevent warping and to facilitate later insertion. They should be stored in water in a denture cup properly labeled with the patient's identification. *C* - CORRECTYes. You have selected the correct response. Brushing them is the only way to remove debris that might have accumulated on and between the teeth. It is important to avoid using hot water to rinse dentures, as it can damage some denture materials.

HISTORY Your patient is a 57-year-old male with aspiration pneumonia. He has been living in a metropolitan subsidized housing facility with no significant support system. ASSESSMENT This patient has a history of type 2 diabetes mellitus, coronary artery disease, and a cerebrovascular accident. He smokes about one pack of cigarettes per day and also has a history of significant alcohol use. 1.You enter your patient's room and prepare to perform a more thorough skin assessment while bathing him. He seems reluctant to allow you to proceed with this process. You respond appropriately by A. informing him that his lack of hygiene puts the other patients at risk for infection. B. asking a nursing assistant to help immobilize the patient when you bathe him. C. explaining that you understand his reluctance but must check his skin for injuries. 2.You prepare your patient for bathing. You place your supplies within reach, and then you A. start the procedure, keeping the patient covered with his bed linens. B. replace the linens with a bath blanket, then begin the procedure. C. remove the patient's bed sheets and blanket and begin the bathing process. 3.You begin the bathing process, promoting the patient's comfort by A. encouraging the patient to assist as much as possible. B. performing the bath procedure as quickly as possible. C. educating the patient about the improper hygiene you previously observed. 4.While washing the patient's face, you note the presence of cerumen in his left ear canal. You A. use a cotton-tipped applicator to remove the cerumen from the canal. B. use a damp cloth or gentle irrigation to loosen debris from the canal. C. continue the bath because cerumen in the ear canal is an expected finding. 5.You notice that your patient has mild edema of the lower extremities. You encourage venous return by A. massaging the leg tissue deeply while washing the skin. B. applying firm pressure to the calves with a kneading motion. C. washing his legs using long, gentle, distal-to-proximal strokes. 6.While washing the patient's ankles and feet, you note the absence of hair and that the skin has a glossy appearance. The most likely explanation for these findings is A. a fungal infection of the skin. B. a lack of blood flow to these tissues. C. frequent exposure to cold.

1. A - INCORRECT No. This is not the correct choice. This is a nontherapeutic response that is likely to make the patient defensive and less likely to cooperate. B - INCORRECT No. This is not the correct choice. Restraining a patient is always a last resort, plus it creates an adversarial relationship between you and the patient. C - *CORRECT* Yes. You have selected the correct response. Your best approach is a therapeutic response that helps to validate the patient's feelings while explaining the procedure, including what you will do and why. Assure him that you will minimize any discomfort or embarrassment he might feel, while also performing an important assessment of his skin. 2.A - INCORRECT No. This is not the correct choice. Soiled linens will contaminate newly washed skin. B - *CORRECT* Yes. You have selected the correct response. It is best to cover the patient's top bed sheet with a bath blanket and remove the dirty linens, leaving the blanket in place. This minimizes the patient's exposure and helps keep him warm and comfortable during bathing. C - INCORRECT No. This is not the correct choice. This is likely to increase the patient's discomfort and embarrassment. 3.*A* - CORRECT Yes. You have selected the correct response. When the patient participates in his care, he is likely to feel more in control and ultimately more comfortable with the procedure. B - INCORRECTNo. This is not the correct choice. Although "getting it over with" might seem like it would minimize discomfort, the patient might perceive your rushed demeanor as a lack of caring. Also, rushing your assessment might make you overlook skin areas that need special attention. C - INCORRECTNo. This is not the correct choice. Patient education is always important, but pointing out deficiences before developing a trusting relationship with the patient might lead to defensiveness or hostility. 4. A - INCORRECT No. This is not the correct choice. Using a cotton-tipped applicator might push cerumen deeper into the ear canal and possibly injure the ear tissues. *B* - CORRECTYes. You have selected the correct response. Gentle wiping or irrigation can effectively remove cerumen without causing injury. C - INCORRECTNo. This is not the correct choice. If cerumen becomes impacted, it can cause hearing loss and predispose the ear canal to infection. 5.A - INCORRECT No. This is not the correct choice. Deep pressure can cause tissue injury while also contributing to skin breakdown. B - INCORRECTNo. This is not the correct choice. Calf pressure can cause any thrombi present to dislodge and become emboli. *C* - CORRECTYes. You have selected the correct response. Using this technique while the patient is supine encourages blood return to the heart while applying minimal pressure. 6A - INCORRECT No. This is not the correct choice. Fungal infections of the skin, such as tinea corporis, are characterized by reddened, flaky lesions. *B* - CORRECTYes. You have selected the correct response. A decrease in tissue perfusion (poor circulation) results in thinning of the skin and hair loss. C - INCORRECTNo. This is not the correct choice. Exposure to cold weather can make the tissues pale, but should not cause hair loss.

What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? (Select all that apply). 1. Prone position 2. Sims' position 3. Semi-Fowler's position with head to side 4. Trendelenburg position 5. Supine position

1. Answer: 2, 3. Place the unconscious patient in semi-Fowler's position with head to the side or use the Sims' position to help avoid aspiration while performing oral care. The supine and Trendelenburg positions would make it easier for a patient to aspirate. The prone position would not be suitable for accessing the oral cavity.

A patient with a malignant brain tumor requires oral care. The patient's level of consciousness has declined, with the patient only being able to respond to voice commands. Place the following steps in the correct order for administration of oral care. 1. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway. 2. Raise bed, lower side rail, and position patient close to side of bed with head of bed raised up to 30 degrees. 3. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces first. 4. For patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral cavity. 5. Remove partial plate or dentures if present. 6. Gently brush tongue but avoid stimulating gag reflex.

2, 5, 1, 3, 6, and 4

While planning morning care, which of the following patients would have the highest priority to receive his or her bath first? 1. A patient who just returned to the nursing unit from a diagnostic test. 2. A patient who prefers a bath in the evening when his wife visits and can help him. 3. A patient who is experiencing frequent incontinent diarrheal stools and urine. 4. A patient who has been awake all night because of pain 8/10.

3. A patient with urinary and bowel incontinence needs perineal cleaning with each episode of soiling, whereas patients who are normally inactive during the day and have skin that tends to be dry may need to bathe only twice a week.

When you are assigned to a patient who has a reduced level of consciousness and requires mouth care, which physical assessment techniques should you perform before the procedure? (Select all that apply). 1. Oxygen saturation 2. Heart rate 3. Respirations 4. Gag reflex 5. Response to painful stimulus

6. Answer: 3, 4. Check a patient's respirations and whether there is a gag reflex present to determine risk for aspiration and to establish a baseline for the patient's condition.

A nurse is listening to a student provide instruction to a patient who is having difficulty with activities needed to care for soft contact lenses. Which of the following statements by the nursing student might require some correction by the nurse? 1. Use tap water to clean soft lenses. 2. Follow recommendations of lens manufacturer when inserting the lenses. 3. Keep lenses moist or wet when not worn. 4. Use fresh solution daily when storing and disinfecting lenses.

7. Answer: 1. The patient should not use water to clean soft contact lenses.

Aging causes the rate of epidermal cell replacement to slow down, become thinner and lose resiliency. True False

Aging causes the rate of epidermal cell replacement to slow down, become thinner and lose resiliency. Correct! True

A nurse uses long firm, strokes distal to proximal while bathing a patient's legs because: 1. It promotes venous circulations. 2. It covers a larger area of the leg. 3. It completes care in a timely fashion. 4. It prevents blood clots in legs.

Answer 1. Bathing a patient with long, firm strokes distal to proximal promotes circulation and increases venous return.

The American Dental Association suggests that patients who are at risk for poor hygiene use the following interventions for oral care: (Select all that apply). 1. Use antimicrobial toothpaste. 2. Brush teeth 4 times a day. 3. Use 0.12% chlorhexidine gluconate (CHG) oral rinses. 4. Use a soft toothbrush for oral care. 5. Avoid cleaning the gums and tongue.

Answer: 1, 3, 4. The American Dental Association guidelines (2014) for effective oral hygiene include brushing the teeth at least twice a day with an American Dental Association-approved fluoride toothpaste. Use antimicrobial toothpastes and 0.12% CHG oral rinses for patients at increased risk for poor oral hygiene (e.g., older adults and patients with cognitive impairments and who are immunocompromised). Rounded soft bristles stimulate the gums without causing abrasion and bleeding. Patients should clean gum and the surface of the tongue.

An 88-year-old patient comes to the medical clinic regularly. During a recent visit the nurse noticed that the patient had lost 10 lbs in 6 weeks without being on a special diet. The patient tells the nurse that he has had trouble chewing his food. Which of the following factors are normal aging changes that can affect an older adult's oral health? (Select all that apply). 1. Dentures do not always fit properly. 2. Most older adults have an increase in saliva secretions. 3. With aging the periodontal membrane becomes tighter and painful. 4. Many older adults are edentulous, and remaining teeth are often decayed. 5. The teeth of elderly patients are more sensitive to hot and cold.

Answer: 1, 4. Dentures or partial plates do not always fit properly, causing pain and discomfort. Many older adults are edentulous (without teeth), and the teeth that are present are often diseased or decayed. An age-related decline in saliva secretion is common. The periodontal membrane weakens with aging, making the area prone to infection. Normally aging does not affect temperature sensitivity.

The student nurse is teaching a family member the importance of foot care for his or her mother, who has diabetes. Which safety precautions are important for the family member to know to prevent infection? (Select all that apply). 1. Cut nails frequently. 2. Assess skin for redness, abrasions, and open areas daily. 3. Soak feet in water at least 10 minutes before nail care. 4. Apply lotion to feet daily. 5. Clean between toes after bathing.

Answer: 2, 4, 5. Because of a patient's risk for infection, it is important to assess skin for redness, abrasions, and open areas daily. Apply lotion to feet daily to keep the skin hydrated, but do not leave excess lotion on the skin. Clean between toes carefully after bathing to avoid maceration. Do not cut nails or soak the feet of a patient with diabetes because this may create skin breakdown and open sores, leading to skin breakdown or infection.

integrity of the oral mucosa depends on salivary secretion. Which of the following factors impairs salivary secretion? (Select all that apply). 1. Use of cough drops 2. Immunosuppression 3. Radiation therapy 4. Dehydration 5. Presence of oral airway

Answer: 3, 4. Radiation therapy reduces salivary flow. Dehydration impairs salivary secretion in the mouth. Cough drops increase sugar or acid content in the mouth, causing caries. Immunosuppression causes inflammation and bleeding of the gums. An oral airway irritates oral mucosa.

A nurse is assigned to care for the following patients. Which of the patients is most at risk for developing skin problems and thus requiring thorough bathing and skin care? 1. A 44-year-old female who has had removal of a breast lesion and is having her menstrual period. 2. A 56-year-old male patient who is homeless and admitted to the emergency department with malnutrition and dehydration and who has an intravenous line. 3. A 60-year-old female who experienced a stroke with right-sided paralysis and has an orthopedic brace applied to the left leg. 4. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool.

Answer: 4. All of the patients require careful bathing. The 44-yearold female needs good perineal hygiene. The 56-year-old patient is at risk for drying and fragility of the skin. The 60-year-old patient has reduced sensation and mobility and thus is unaware of skin problems or pressure areas. However, the 70-year-old patient has reduced circulation, which increases risk for infection, and is likely unaware of skin problems because of dementia. The presence of stool will also irritate the skin.

A nurse is caring for an adult patient who is NPO. The patient is refusing oral care. Which of the following is an appropriate response by the nurse? A. "Since you are not eating, we can wait and do it before bedtime." B. "Oral care is still important, even though you are not eating." C. "I'll give you a sip of water to swish around in your mouth, and then you can spit it out." D. "We will wait until your family gets here to help."

B. "Oral care is still important, even though you are not eating."

2. A young girl with long hair is experiencing a problem with matting. The most appropriate action to take would be: A. cutting the matted hair away. B. braiding the hair to reduce tangles. C. using a grease-type product to tame the hair. D. keeping the hair oil free by applying powder every morning.

B. braiding the hair to reduce tangles.

Nursing Diagnosis Common diagnoses associated with hygiene:

BATHING SELF-CARE DEFICIT ➢Activity intolerance ➢Bathing self-care deficit ➢Dressing self-care deficit ➢Impaired physical mobility ➢Impaired oral mucous membrane ➢Ineffective health maintenance ➢Risk for infection

Bathing a patient is an excellent way to assess your patient's skin condition, flexibility, range of motion and facilitate the development of a therapeutic relationship. True False

Bathing a patient is an excellent way to assess your patient's skin condition, flexibility, range of motion and facilitate the development of a therapeutic relationship. Correct! True

A nurse is caring for an unconscious patient. Which of the following statements by the nurse indicates an understanding of providing good oral hygiene for the patient? A. "I'll swab the patient's mouth with lemon-glycerin swabs." B. "I'll swab the patient's mouth with mouthwash." C. "Ill swab the patient's mouth with diluted hydrogen peroxide." D. "I'll swab the patient's lips with a very small amount of mineral oil."

C. "Ill swab the patient's mouth with diluted hydrogen peroxide."

Clean the sensitive sensory tissues in a way that prevents ____ and ____ for a patient, such as by taking care to not get ___ in his or her eyes.

Clean the sensitive sensory tissues in a way that prevents injury and discomfort for a patient, such as by taking care to not get soap in his or her eyes.

Match the term with the correct definition. Complete bed bath Partial bed bath Tub bath Shower Bag bath

Complete bed bath - administered to a totally dependent patient in bed Partial bed bath - for those who cannot reach certain spots and/or just bathing the body parts that would cause discomfort if not bathed Tub bath - immersion in water Shower - sits or stands under a continuous stream of water Bag bath - Pre-moistened cloths with a no-rinse cleanser

Consider ____grooming routines, and ____ care

Consider normal grooming routines, and individualize care if a patient takes showers at night, individualize hygiene care to accommodate this.

Which patient is most important for the nurse to encourage daily inspection of their feet? A 72 year old with dementia An 18 year old swimmer A 20 year old smoker (10 cigarettes/day) A 62 year old diabetic

Correct! A 62 year old diabetic Foot ulceration is the most common precursor to lower-extremity amputations among people with diabetes.

The functions of the skin include which of the following? Select All That Apply. Excretion Temperature Control Secretion Protection

Correct! Excretion Correct! Temperature Control Correct! Secretion Correct! Protection

The use of Q tips is encouraged to promote ear hygiene. True False

Correct! False "The only thing that should ever be placed in your ear is your elbow" Objects inserted in the ear canal can rupture the ear drum and may also cause cerumen (ear wax) to become impacted in the ear canal.

A normally shaped nail is transparent, smooth and concave in shape. True False

Correct! False Normal nails are transparent, smooth and convex in shape.

Which of the following can affect a patient's desire to maintain their hygiene? Select All That Apply Fatigue Complaint of pain Gender Depression Socioeconomic status Mental status

Correct! Fatigue Correct! Complaint of pain (false) Gender Correct! Depression Correct! Socioeconomic status Correct! Mental status

Perineal care for male patients should start with washing the tip of the penis at urethral meatus first, using circular motion, clean from meatus outward. True False

Correct! True This direction of cleaning moves from an area of least contamination to area of most contamination, preventing microorganisms from entering urethra.

provide patient-centered care with regard to hygiene? Select All That Apply Maintaining privacy Shaving an unkempt beard Providing gender-congruent caregivers if requested Allowing family to participate in care

Correct! Maintaining privacy (incorrect) Shaving an unkempt beard Do not cut or shave hair without prior discussion with patient or family because of cultural or religious beliefs. Correct! Providing gender-congruent caregivers if requested Correct! Allowing family to participate in care

Dental caries

Dental caries—tooth decay.

Direction in which a nurse washes patients' extremities. Proximal to distal Front to back Distal to proximal Back to front

Distal to proximal

___, ____, and ____ require special attention to prevent infection, odor, and injury.

Feet, hands, and nails require special attention to prevent infection, odor, and injury.

What is the nurse going to do when giving a patient a tub bath

Gather all necessary supplies Place a rubber mat on the tub floor Assist the patient into the bathroom Instruct the patient on using safety bars when getting in and out of the tub Instruct the patient to remain in the tub for no longer than 20 min.

Gingivitis

Gingivitis—inflammation of the gums.

Hair _, _, and _indicate general health status.

Growth, distribution, and pattern indicate general health status.

Hormonal changes, nutrition, emotional stress, physical stress, aging, infection, and other illnesses can affect ____ characteristics.

Hormonal changes, nutrition, emotional stress, physical stress, aging, infection, and other illnesses can affect hair characteristics.

Hygiene care is ____ routine.

Hygiene care is *never* routine.

Implementation Acute, restorative, and continuing care

Hygiene measures vary by patient needs and health care setting.

Safety Guidelines for Nursing Skills

Identify the patient with two identifiers. Move from the cleanest to less clean areas. Use clean gloves for contact with nonintact skin, mucous membranes, secretions, excretions, or blood. Test the temperature of water or solutions. Use principles of body mechanics and safe patient handling. Give proper direction to NAP when delegating.

When planning morning hygiene care for a postoperative patient, which of the following actions should the nurse include? inform the patient when morning hygiene care is provided at the hospital. Schedule to provide care to the patient and her roommate at the same time. Ask the patient in what order she typically performs her morning routine. Plan to provide care before the next scheduled dose of pain medication.

Inform the patient when morning hygiene care is provided at the hospital. ~The nurse should take other factors into consideration when planning morning hygiene care. Schedule to provide care to the patient and her roommate at the same time. ~Hygiene care requires intimate contact and should not be grouped with others. *Ask the patient in what order she typically performs her morning routine* ~The patient's plan for routine morning care should be tailored to the uniqueness of the patient's typical routine. Plan to provide care before the next scheduled dose of pain medication. ~Pain medication should be given prior to daily care if possible.

A nurse is assisting a patient with personal hygiene care. Which of the following actions by the nurse will reduce the risk of infection? Massaging reddened areas of the patient's skin Washing eyes from the outer canthus to the inner canthus Washing the patient from the shoulder down to the fingertips with smooth, short strokes Cleaning the least-soiled areas prior to cleaning the most-soiled areas

Massaging reddened areas of the patient's skin ~Massaging can cause breaks in the skin's surface capillaries and increases the risk for skin breakdown. Washing eyes from the outer canthus to the inner canthus ~Eyes should be washed from the inner canthus to the outer canthus to prevent secretions from entering the nasolacrimal duct. Washing the patient from the shoulder down to the fingertips with smooth, short strokes ~The patient's arm should be bathed using long, firm strokes and proceeding from the distal to the proximal areas. *Cleaning the least-soiled areas prior to cleaning the most-soiled areas* ~The least-soiled areas should be cleaned first to prevent moving more contaminants into the cleaner areas.

____, exposure to ____, and ____breathing can impair salivary secretion.

Medications, exposure to radiation, and mouth breathing can impair salivary secretion.

Mustache and beard care

Mustache and beard require daily grooming because of food particles and mucus that collect on the hair. comb and trim/shave if permission

Normal oral mucosa is ___, ___, ___, ___, and without lesions.

Normal oral mucosa is light pink, soft, moist, smooth, and without lesions.

Match the term with the correct definition. Pediculosis capitis Pediculosis corporis Pediculosis Pubis Alopecia Tinea Pedis

Pediculosis capitis - head lice Pediculosis corporis - body lice Pediculosis Pubis - crab lice (pubic lice) Alopecia - hair loss Tinea Pedis - athlete's foot

*Nursing Process: Planning* Set priorities based on _____required, extent of ____, nature of ____

Set priorities based on assistance required, extent of problems, nature of diagnoses

A nurse observes an assistive personnel (AP) make a client's bed while the client is out of the room. Which of the following actions by the AP is appropriate for this task? The AP records the task when it is completed. The AP wears sterile gloves while making the bed. The AP makes a mitered corner with the blanket and spread. The AP reuses the patient's blanket and spread.

The AP records the task when it is completed. ~Making a bed does not require documentation. The AP wears sterile gloves while making the bed. ~Clean gloves should be worn if the linen is soiled. The AP makes a mitered corner with the blanket and spread. ~A mitered corner should be made with the sheet, blanket, and spread. *The AP reuses the patient's blanket and spread* ~The mattress pad, sheet, blanket, and spread may be reused for the same patient if they are not wet or soiled.

The condition of a patient's ____ and ____ influences his or her ability to perform hygiene care.

The condition of a patient's hands and feet influences his or her ability to perform hygiene care.

The normal nail is ____, ____, and ___, with a pink nail bed and a translucent white tip.

The normal nail is transparent, smooth, and convex, with a pink nail bed and a translucent white tip.

The oral cavity is lined with __________

The oral cavity is lined with mucous membranes.

The sense of ____ is an important aid to appetite

The sense of smell is an important aid to appetite

The hair shaft itself is ___, and physiological factors do/do not directly affect it. HOWEVER...

The shaft itself is lifeless, and physiological factors do not directly affect it. ➢However, hormonal and nutrient deficiencies of the hair follicle cause changes in hair color or condition.

One way to determine a patient's nutritional status is to assess the condition of their hair. True False

True

Implementation

Use caring to reduce anxiety, promote comfort. Administer meds for symptoms before hygiene. Be alert for patient's anxiety or fear. Assist and prepare patients to perform hygiene as independently as possible. Discuss signs and symptoms of problems. Inform patients about community resources.

When hygiene care is provided, the ___, ___, and ____ require careful attention.

When hygiene care is provided, the eyes, ears, and nose require careful attention.

Xerostomia

Xerostomia—dry mouth.

Nursing Process: Assessment

assess patient expectations about hygiene Self-care ability Skin Feet and nails Oral cavity Hair and hair care Eyes, ears, and nose Use of sensory aids Hygiene care practices Cultural influences

*Care of the eyes, ears, and nose:* Eyeglasses

cool water to clean lenses soft cloth for drying put in case to store

Patients with special needs: diabetes, artificial airways, unconscious, chemotherapy

diabetics or those on chemotherapy need frequent hygiene care (risk for periodontal disease) artificial airways; increases susceptibility to dry mouth unconscious; no gag reflex, need suction during mouth care to avoid aspiration

Foot and nail care

do not soak feet/hands of diabetics or peripheral vascular disease causes MACERATION of tissue

Back rub

effleurage - long, slow gliding strokes of a message reduce anxiety, respiratory rate heart rate

During hygiene, assess:

emotional status, health promotion practices, health care education needs

Nasal care

if patient cannot remove nasal secretions, use wet wash cloth or q-tips remove secretions by gentle suctioning change tape of nasal tubes once a day to prevent maceration, wipe and dry nasal surface

Shaving

if patient prone to bleeding must use personal electric razor soften skin with warm water and use shaving cream long strokes on face, short on upper lip

stomatitis

inflammation of the mouth -burning/pain common with rediation

Ear care

moistened washcloth gently rotate into ear canal to remove cerumen irrigate if impacted

*Care of the eyes, ears, and nose:* Contact lenses

must be removed periodically to prevent ocular infections/abrasions when patients are admitted unconscious or confused, check to remove

*Care of the eyes, ears, and nose:* Medical devices

oxygen tube/feeding/nasotracheal cushion and protect skin with dressing cleanse and check for irritation daily

While performing a complete bed bath for a patient, the nurse should. raise the room temperature. completely remove the linens. add soap to the water in the basin before beginning the bath. complete the bathing for one side of the body at a time.

raise the room temperature. ~Raising the temperature of the room will help keep the patient warm while various parts of the body are exposed and washed. completely remove the linens. ~The top linens should not be completely removed without covering the patient with a bath blanket first. The bottom linens should be removed after the bath to keep the new linens from getting wet. add soap to the water in the basin before beginning the bath. ~Soap should not be added to the water in the basin; irritation to the eyes can occur if this is done. complete the bathing for one side of the body at a time. ~Bathing should be completed from top to bottom, not side to side

*Care of the eyes, ears, and nose:* Artificial eyes

retract lower eyelid slight pressure below eye warm saline to clean' clean edges of eye socket

Patients at risk for hygiene problems

side effects of meds or other medical therapy; lack of knowledge; immobilization and inability to perform task; or physical condition that potentially injures the skin, mouth, feet, nails and hair.

Hearing aid care

turn off or remove the battery when not being worn. Store it in a safe, padded container. b. Clean at least weekly. Wipe the aid off and use a toothpick, pipe cleaner, or pick to clean the channel. Do not use alcohol to clean the aid as this can cause drying and cracking. .when changing the batteries , turn off the aid first. Keep several new batteries available. Typically, a battery will last about 80 hours.

*Care of the eyes, ears, and nose:* Basic eye care

washing from inner canthus to the outer canthus with warm water on wash cloth unconscious patients require more may put lubricating eye drops if physician orders

Hair and scalp care

➢Brushing and combing •Distributes oil •Prevents tangling, as does braiding •Obtain permission before braiding or cutting. •Combing is more effective than use of pediculicidal shampoos in the case of head lice

Oral hygiene

➢Brushing removes particles, plaque, and bacteria; massages the gums; and relieves unpleasant odors and tastes. ➢Flossing removes tartar at the gum line. ➢Rinsing removes particles and excess toothpaste.

Patient outcomes

➢Evaluate after each hygiene intervention ➢Use teach back ➢If outcomes were not met, revise the care plan

Shampooing

➢Frequency depends on patient routines and hair condition

*Nursing Process: Planning* Teamwork and collaboration

➢Health care team members ➢Family ➢Community agencies

Denture care

➢Keep dentures covered in water when they are not worn ➢Store in an enclosed, labeled cup with the cup placed on patient's bedside stand

Patient's room environment

➢Maintaining comfort •Temperature, noise, lighting, ventilation, odors ➢Room equipment over-bed table, bedside stand, chairs and bed

Implementation Health promotion

➢Make instructions relevant .➢Adapt instruction to patient's facilities and resources. ➢Teach the patient ways to avoid injury. ➢Reinforce infection control practices.

*Nursing Process: Planning* Goals and outcomes

➢Partner with the patient and family ➢Measurable, achievable, individualized

Bathing and skin care

➢Therapeutic: sitz, medicated ➢Complete bed bath ➢Shower ➢Partial bed bath ➢Soap and water vs. Chlorhexidine Gluconate (CHG) ➢Perineal care

Evaluation Through the patient's eyes...

➢Were the patient's expectations met? during assessment you collect info on patients expectations of care during and after hygiene determine if patient care is being acceptable provided